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International Journal of Obesity (2013) 37, 1415–1421
& 2013 Macmillan Publishers Limited All rights reserved 0307-0565/13
www.nature.com/ijo
ORIGINAL ARTICLE
The effect of physicians’ body weight on patient attitudes:
implications for physician selection, trust
and adherence to medical advice
RM Puhl, JA Gold, J Luedicke and JA DePierre
BACKGROUND: Research has documented negative stigma by health providers toward overweight and obese patients, but it is
unknown whether physicians themselves are vulnerable to weight bias from patients.
PURPOSE: This study assessed public perceptions of normal weight, overweight or obese physicians to identify how physicians’
body weight affects patients’ selection, trust and willingness to follow the medical advice of providers.
METHODS: An online sample of 358 adults were randomly assigned to one of three survey conditions in which they completed a
questionnaire assessing their perceptions of physicians who were described as normal weight, overweight or obese. Participants
also completed a measure of explicit weight bias (Fat Phobia Scale) to determine whether antifat attitudes are associated with
weight-related perceptions of physicians.
RESULTS: Respondents reported more mistrust of physicians who are overweight or obese, were less inclined to follow their
medical advice, and were more likely to change providers if the physician was perceived to be overweight or obese, compared to
normal-weight physicians who elicited significantly more favorable reactions. These weight biases remained present regardless of
participants’ own body weight. Inspection of interaction effects revealed opposing effects of weight bias between the obese/
overweight and normal-weight physician conditions. Stronger weight bias led to higher trust, more compassion, more inclination to
follow advice, and less inclination to change doctors when the physician was presented as normal weight. In contrast, stronger
weight bias led to less trust, less compassion, less inclination to follow advice and higher inclination to change doctors when the
physician was presented as obese.
CONCLUSIONS: This study suggests that providers perceived to be overweight or obese may be vulnerable to biased attitudes
from patients, and that providers’ excess weight may negatively affect patients’ perceptions of their credibility, level of trust and
inclination to follow medical advice.
International Journal of Obesity (2013) 37, 1415–1421; doi:10.1038/ijo.2013.33; published online 19 March 2013
Keywords: stigma; bias; physician
INTRODUCTION
Stigma toward obese persons is pervasive in North America.
Obese individuals are vulnerable to harmful weight-based
stereotypes, including perceptions that they are lazy, lacking in
willpower, indisciplined and unintelligent.1,2 These stereotypes
give way to stigma, prejudice and discrimination in multiple
domains of living, including the workplace, health-care facilities,
educational institutions, the mass media and even in close
interpersonal relationships.1,3
Of concern, these negative stereotypes have emerged consistently in the health-care setting, with multiple studies documenting biased attitudes toward obese patients by physicians, nurses
and other health-care professionals.4–9 Although considerable
research has illustrated negative stigma by physicians toward
overweight and obese patients (see Puhl and Heuer1 for a
review),1 little research to date has examined whether physicians
themselves could be vulnerable to weight bias from patients.
That is, to what degree do patients hold stigmatizing attitudes
toward physicians who are overweight or obese? Given that
two-thirds of American adults are either overweight or obese,10
many health care providers also struggle with overweight and
obesity11 and may be perceived differently by their patients
compared to thinner physicians.
This notable gap in research is important to address for several
reasons. The provider–patient relationship is pivotal for risk
reduction, disease prevention and ultimately disease outcomes
for the patient.12 When addressing health behaviors like smoking,
exercise, diet and alcohol usage, the provider–patient interaction
is key for identifying risk factors and disease, and for counseling
patients on appropriate treatment actions.13 Yet, the degree
to which these interactions are effective and successful could be
related to actual or perceived health-related behaviors of doctors
themselves. For example, evidence suggests that physicians with
lower resting heart rates are more likely to counsel their patients
on exercise14 and non-smoking physicians are more likely to
counsel their patients on smoking cessation.15 Some research
shows that health professionals of a ‘normal weight’ are more
confident in their weight management practices, perceive fewer
barriers to weight management for their patients, and have more
positive expectations for patient health outcomes.16 Similarly, a
Rudd Center for Food Policy and Obesity, Yale University, New Haven, CT, USA. Correspondence: Dr RM Puhl, Rudd Center for Food Policy and Obesity, Yale University, 309
Edwards Street, New Haven, CT 06511, USA.
E-mail: rebecca.puhl@yale.edu
Received 19 November 2012; revised 9 January 2013; accepted 16 January 2013; published online 19 March 2013
Physicians’ body weight and patient attitudes
RM Puhl et al
1416
recent study found that physicians with a body mass index (BMI)
in the ‘normal-weight’ range have greater confidence in their
abilities to provide diet and exercise counseling to their obese
patients compared to physicians with higher BMI, and believe that
overweight/obese patients would be less likely to trust weight loss
advice from overweight/obese doctors.17
Personal health behaviors of physicians have also been
associated with patients’ perceptions of their decreased credibility.18 For example, one study found that even if physicians talk
to their patients about reducing unhealthy behaviors, patients are
less likely to listen to physicians who are perceived as unhealthy.19
In addition, experimental research has found that physicians who
disclose health, diet and exercise habits are perceived as more
believable, healthier and more motivating by patients compared
to physicians who do not disclose health behaviors.20
However, the degree to which a physician’s body weight may
affect patient perceptions and reactions to physicians remains
poorly understood, and has received very little research attention.
Of the limited research that has been published in this area, one
study found that non-obese physicians are perceived to be better
at providing health advice than obese physicians,13 and another
study illustrated that patients listen more strongly to the health
advice of a non-obese physician, as compared to an obese
physician.21 However, questions remain regarding the impact that
a physician’s body weight has on patients’ perceptions of trust
and credibility of the physician, their comfort level in discussing
personal health behaviors, the degree to which they would follow
advice to improve health behaviors and even their selection of
providers.
The present study aimed to assess public perceptions of normal
weight, overweight or obese physicians to better understand how
these perceptions affect the doctor–patient relationship, including
physician selection, physician trust and following medical advice.
It was hypothesized that participants would assign more negative
ratings on these characteristics to physicians who were described
as being overweight or obese compared to physicians described
as being normal weight. These questions were examined in an
experimental paradigm via an online self-report survey of the
general population. This study additionally examined whether
certain participant characteristics (for example, gender, age, body
weight and race) affect their responses and perceptions of
physicians’ weight and the doctor–patient relationship.
MATERIALS AND METHODS
Participants
Participants were recruited from an online database (eLab) hosted by the
Yale School of Management (http://elab.som.yale.edu). This website draws
from a sample of approximately 20 000 adults from across the United
States, who are recruited through advertisements on social networking
websites. Registered participants in the panel are notified via e-mail when
studies are posted, and they are invited to participate in any studies of
their choosing based on the description of the study. The participation was
voluntary, and participants were compensated with entry into a raffle to
win a gift card. The study was approved by the university’s institutional
review board. The authors aimed to obtain a sample of approximately 300
participants, to ensure that each of the three experimental conditions
contained at least 100 participants. Three hundred and ninety-one
participants completed the survey, of which 33 individuals were removed
due to item-nonresponse missing data, resulting in an analysis sample of
N ¼ 358. Participants were randomly assigned to the experimental
groups (group 1, normal-weight physician: n ¼ 123, 34%; group 2,
overweight physician: n ¼ 117, 33%; group 3, obese physician: n ¼ 118,
33%). Participants’ demographic characteristics across conditions were
compared using a multinomial logistic regression model with group
membership as outcome and age, gender, education, income and race/
ethnicity as predictors. Results showed no differences in participant
characteristics across conditions, with the exception of a weakly significant
overrepresentation of participants from the lowest educational category
(high-school degree or less) in group 1.
International Journal of Obesity (2013) 1415 – 1421
Procedure
An online experimental survey was developed to assess participant
perceptions and opinions of physicians described as normal weight,
overweight or obese. Upon agreeing to participate in the study and
entering the survey, participants first completed demographic information
and general questions about their opinions of physician health behaviors
and selecting a physician (see below), and were then randomly assigned to
one of three survey conditions. All survey conditions contained identical
questions to assess participants’ perceptions of physicians; however, the
questions differed according to whether they referred to physicians who
were normal weight, overweight or obese. Specifically, in one condition
participants were asked their opinions about physicians who are ‘normal
weight’, a second condition asked the same questions about ‘overweight’
physicians and a third condition asked these questions about physicians
who are ‘obese’. It is important to note that, this classification of body
weight of physicians was not objectively defined to participants, and thus,
perceptions of what constitutes the descriptors of ‘normal weight’,
‘overweight’, or ‘obese’ could vary across participants. However, previous
work has highlighted the important role of individuals’ perceptions in
creating the meaning and context within which their behavior is
enacted,22 and recent experimental research investigating the subjective
categorization of the weight of other individuals (across multiple target
and rater characteristics, including gender, race and BMI) found very few
significant differences of weight ratings.23 Thus, in order to understand the
implications of weight-related perceptions for the doctor–patient relationship (such as physician selection, physician trust or adherence to medical
advice), it is informative to assess participants’ subjective perceptions of a
doctor’s weight rather than the doctor’s actual weight. For example,
if a patient loses trust in the medical advice of a doctor because
(s)he perceives that the doctor weighs too much, it is less relevant whether
or not the doctor was in fact ‘obese’ by BMI standards. Rather, the
importance lies in whether the patient’s perception that the doctor has
excess weight influences his/her feelings about the doctor–patient
relationship.
Measures
Demographic and weight information. Participants were asked
demographic questions including their age, gender, race/ethnicity, level
of education/income, as well as height and weight. Height and weight
information were collected to determine the BMI of participants. This
information is important for examining responses among individuals
within different weight categories. Of the N ¼ 358 participants in the
analysis sample, n ¼ 56 participants (16%) had missing BMI data, which
were multiply imputed (M ¼ 20) in order to avoid biased estimates.
Physician health behaviors. Following demographic information, participants were asked to provide their opinions in response to six questions
about their opinions of health behaviors among physicians, with respect to
whether doctors should or should not smoke cigarettes, drink alcohol,
exercise regularly, eat a well-balanced diet, see a doctor regularly and
obtain yearly preventive screenings (for example, ‘In general, doctors
should not smoke cigarettes’). Items were presented with Likert rating
scale response options (from 1 ¼ ‘strongly disagree’ to 5 ¼ ‘strongly agree’)
in order to determine what behaviors participants view as healthy or
unhealthy in a physician. Chronbach’s alpha for this measure was 0.81.
Physician selection. Participants were then asked five questions about
how important a physician’s body weight and physical appearance are
when choosing a doctor for themselves (for example, ‘When choosing a
doctor, his/her body weight is important to me’ and ‘It is important to me
that my doctor is at a healthy weight’). Questions were asked using a fivepoint Likert rating scale (from 1 ¼ ‘strongly disagree’ to 5 ¼ ‘strongly
agree’). Chronbach’s alpha for this measure was 0.90.
Physician compassion. Following randomization to one of the three
survey conditions, participants were asked their opinions about normal
weight, overweight or obese physicians. Five questions were asked to
assess participants’ perceptions about the compassion and bedside
manner of their physician if he or she was normal weight, overweight or
obese. Questions specifically asked the degree to which participants
believed the doctor would listen carefully to them, understand their
concerns and understand the difficulties of losing weight, and the extent
that they would feel comfortable talking to their physician and expressing
health concerns (for example, ‘I believe a [normal weight/overweight/
& 2013 Macmillan Publishers Limited
Physicians’ body weight and patient attitudes
RM Puhl et al
1417
obese] doctor would listen carefully to what I have to say’). Higher scores
on this measure reflect higher compassion. Chronbach’s alpha was 0.80 for
this measure.
31% overweight (BMI 25.0–29.9) and 17% obese (BMIZ30).
Average participant BMI was 25.77 (s.d. ¼ 6.29).
Physician trust/credibility. Five questions were also asked regarding how
much participants would trust the physician, recommend him/her to
friends, feel free to express concerns about their body, have doubts about
the physician’s credibility or feel embarrassed when talking about losing
weight (for example, ‘If my doctor was [normal weight/overweight/obese],
I would have doubts about his/her credibility’). Higher scores on this
measure reflect greater trust toward physicians. This scale demonstrated
very good reliability (alpha ¼ 0.91).
Analysis of variance
Figure 1 shows means and ANOVA results for participants’ ratings
of physician selection, trust, compassion and advice following
across experimental conditions. Figure 1a shows mean differences
across conditions for participant ratings of whether they would
change doctors if their doctor appeared to be normal weight,
overweight or obese, respectively. Respondents who were
presented with questions describing physicians who were either
overweight or obese were significantly more likely to change
doctors than respondents who answered questions about
physicians of a normal body weight. Similarly, perceived trust/
credibility of physicians was significantly worse for physicians who
were presented as overweight or obese, as compared to a normalweight physician (Figure 1b). No significant differences were
found across experimental conditions regarding perceived compassion of physicians (Figure 1c). However, respondents reported
a significantly higher likelihood of following a physician’s
Adherence to physician advice. Ten questions were included to assess
whether a physician’s body weight would influence the extent to which
participants would follow their doctor’s advice both generally and
pertaining to specific health behaviors, including advice about losing
weight, making dietary changes, exercising, smoking cessation, limiting
alcohol consumption, getting preventive screenings, taking regular
medications, and how likely they would believe the doctor’s diagnosis of
their health and that the doctor would be able to develop an effective plan
to help the patient lose weight (for example, ‘If your doctor was [normal
weight/overweight/obese], how likely would you follow his/her advice
about losing weight?’). Three of the questions are modified versions of the
Medical Interview Satisfaction Scale patient satisfaction survey.24 Higher
scores on this measure reflect a higher propensity to follow a physician’s
advice. Chronbach’s alpha for this scale was 0.93.
Explicit weight bias. To assess participants’ attitudes toward obese
persons more generally, they were asked to complete the Fat Phobia
Scale.25 This scale consists of 14 pairs of adjectives commonly used to
describe obese people (for example, ‘active’ versus ‘inactive’, ‘no will
power’ versus ‘has will power’). The adjectives are placed at opposite ends
of a scale that ranges from 1 to 5. Scores below 2.5 indicate positive
attitudes toward obese people, and scores above 2.5 indicate more
negative attitudes toward obese people. Coefficient alphas from various
samples ranged from 0.87 to 0.91.25 Chronbach’s alpha for this scale
was 0.92.
RESULTS
Statistical analysis
Analyses of variance (ANOVAs) and linear regression models
(ordinary least squares (OLS)) were used to analyze the data.
Owing to missing data for BMI in some cases (15.6%), BMI values
were multiply imputed (M ¼ 20) to avoid selection bias.26
Predicting missingness in BMI using a binary logit model with all
covariates that were used in the regression analyses (Table 2) and
all study outcome variables yielded a pseudo R2 of 0.48,
suggesting that missingness is strongly conditioned on the
variables that were used in our analyses. Thus, BMI and other
effects would potentially be biased if observations with missing
BMI data were discarded. Instead, we used a linear imputation
model with all study outcome and predictor variables in order to
predict the missing BMI values, based on simulated parameters
from the posterior distributions that were obtained from a model
fitted to the available (that is, non-missing) data. Between- and
within-imputation variability was taken into account for all
subsequent variance estimation by applying Rubin’s combination
rules.27 All analyses were carried out using Stata version 11.2.
Sample characteristics
Table 1 presents a summary of sample characteristics. Of the total
sample, 57% of participants were female, 70% of participants were
Caucasian, and the average age was 37 years (s.d. ¼ 13.19).
Participant BMI was calculated and classified into categories
according to the clinical guidelines for overweight and obesity in
adults by the National Heart Lung and Blood Institute of the
National Institute of Health.28 This showed 3.6% of the sample to
be underweight (BMIo18.5), 48% normal weight (BMI 18.5–24.9),
& 2013 Macmillan Publishers Limited
Table 1.
Sample characteristics
N
%
Gender
Male
Female
153
205
42.7
57.3
Highest educational degree
HS
Some college
College þ
29
117
212
8.1
32.7
59.2
Annual household income
Under $25 000
$25 000–$49 999
$50 000–$74 999
$75 000–99 999
100 000 þ
58
79
87
52
82
16.2
22.1
24.3
14.5
22.9
251
23
84
70.1
6.4
23.5
Race/ethnicity
White
Black
Other
Weight status
Underweight
Normal weight
Overweight
Obese
Missing
BMI
BMI (multiply imputed, M ¼ 20)a
Age (years)
Item:b physician selection
Scale:c trust/credibility
Scale:c compassion
Scale:c following medical advice
Scale:c physician health behavior
Scale:c anti-fat attitudes (fat
phobia)
N
%
Valid %
11
146
94
51
56
3.1
40.8
26.3
14.2
15.6
3.6
48.3
31.1
16.9
N
M
s.d.
a
302
358
358
358
358
358
358
358
358
25.77
25.71
36.97
2.48
3.55
3.62
3.63
3.85
3.52
6.29
6.32
13.19
1.34
1.12
0.79
0.82
0.70
0.68
0.91
0.80
0.93
0.81
0.92
Abbreviations: BMI, body mass index; HS, high school. aMissing values
were only imputed for BMI, all other statistics are based on the analysis
sample. bLikert scale ranging from 1 to 5. cMean scales based on Likert
scales ranging from 1 to 5.
International Journal of Obesity (2013) 1415 – 1421
Physicians’ body weight and patient attitudes
RM Puhl et al
1418
Table 2.
Linear regression models
Physician selection
Experimental condition
NW physician
OW physician
OB physician
BMI
Age
Females
0.438***
0.581***
0.012
0.008*
0.225*
Trust
Compassion
Following advice
0.461***
0.609***
0.215
0.246*
0.405**
0.520***
0.016
0.010**
0.274**
0.008
0.008
0.338**
0.013
0.009*
0.362***
Highest educational degree
HS
Some college
College þ
0.029
0.067
0.044
0.145
0.067
0.046
0.233
0.162
Annual household income
Under $25 000
$25 000–$49 999
$50 000–$74 999
$75 000–99 999
100 000 þ
0.064
0.015
0.111
0.307*
0.051
0.004
0.099
0.482**
0.240
0.255
0.356
0.473**
0.047
0.157
0.100
0.230
0.198
0.218
0.411*
0.210
0.375
0.376**
0.524*
0.335**
0.312***
0.074
0.135*
0.039
0.005
0.183***
0.242
0.316
0.872**
0.762*
358
358
Race/ethnicity
White
Black
Other
Physician health behavior
Fat phobia
Constant
0.372***
0.107*
N
358
358
Abbreviations: HS, high school; NW, normal weight; OB, obese; OW, overweight. Note: ordinary least squares regression models using multiply imputed data
for body mass index, M ¼ 20; significance levels: *Po0.05, **Po0.01, ***Po0.001; experimental conditions: NW physician; OB physician; OW physician.
Figure 1. Means of outcome measures across experimental conditions and ANOVA results. Note: Each graph in the figure illustrates means of
participants’ ratings on the four primary outcome variables across experimental condition: (a) physician selection, (b) trust towards physician,
(c) compassion towards physician, (d) following physician’s advice. ANOVA results are presented below each graph; a star indicates statistical
significance at Po0.05 with regard to follow-up comparisons using Tukey’s HSD method to account for multiple comparisons, n.s. means not
significant at Po0.05; experimental conditions: NW ¼ normal-weight physician, OW ¼ overweight physician, OB ¼ obese physician.
International Journal of Obesity (2013) 1415 – 1421
& 2013 Macmillan Publishers Limited
Physicians’ body weight and patient attitudes
RM Puhl et al
1419
medical advice if the physician was normal weight, compared
to physicians who were presented as overweight or obese
(Figure 1d). In addition to these main effects, two-way ANOVAs
with ‘condition respondent weight status’ interaction effects
were estimated. No interaction effects were found, indicating that
the differences observed in participants’ ratings across the
experimental conditions did not depend on respondents’ own
weight status.
Regression analyses
Table 2 shows parameter estimates for the differences between the
experimental conditions, controlled for a number of covariates.
Covariates included demographic characteristics, respondent’s BMI,
expected health behavior of physician and weight bias. These
covariates were included to adjust the experimental group effects
with respect to any potentially remaining differences in individual
characteristics across experimental groups. For physician selection,
trust/credibility and following advice, differences in scores
amounted to approximately 1/2 of a standard deviation between
the
overweight/obese
conditions
and
the
normalweight condition, indicative of moderately sized effects. A smaller
difference (approximately 1/4 of a standard deviation in the
outcome variable) was found for compassion, indicating that after
controlling for covariates (see Table 2), respondents perceived the
obese physician to be less compassionate than the normal-weight
physician. This was a small effect, but weakly significant (P ¼ 0.046).
To test whether respondents’ own attitudes about obese
persons (as measured on the Fat Phobia Scale) affected their
opinions of physicians within each experimental condition, we
estimated parameters for ‘attitude condition’ interactions,
controlling for respondents’ BMI. These results are presented in
Table 3, and the condition-specific slopes are graphically
presented in Figure 2, which are displayed for average BMI
baselines. Given significant BMI main effects for variables of
physician selection and trust/credibility, the baselines of these
slopes would decrease or increase, respectively, by approximately
3% of a standard deviation in the dependent variable for every
one unit increase in BMI. The plotted interaction effect in
Figure 2a shows that for respondents in the ‘normal-weight
physician’ condition, the physician selection scores decrease with
increasing anti-fat attitude scores, while the amplitude of this
effect (that is, the difference in the dependent variable over the
full range of anti-fat attitudes) amounts to approximately two
standard deviations. Conversely, for respondents in the obese
physician condition, the physician selection scores increase with
increasing anti-fat attitudes. Thus, participants who expressed
more weight bias (higher fat phobia scores) were less likely to
switch doctors if presented with a normal-weight physician, but
more likely to switch doctors if presented with an obese physician.
The difference between these two slopes is sizable and highly
significant (b ¼ 0.599, Po0.001; the slope for the ‘overweight
physician’ condition was not significantly different from that for
the ‘normal-weight physician’ condition, see Table 3).
Participants who expressed more weight bias (higher fat phobia
scores) additionally reported higher levels of trust/credibility and
adherence to medical advice when presented with a normalweight physician, but reported less trust/credibility and adherence
to medical advice when presented with an obese physician
(see Figures 2b and d). A similar effect, although smaller, was
observed among respondents who were presented with the
overweight physician with respect to following medical advice,
although there was no effect of fat phobia scores on trust/
credibility in this condition (although the slope differed significantly from the slope for the normal-weight physician condition).
Small effects were also observed for perceptions of compassion
among physicians: respondents with higher levels of weight bias
perceived normal-weight physicians to be more compassionate,
with the slope being significantly different from the slopes for
both the overweight and obese physician conditions.
DISCUSSION
To our knowledge, this study is the first to experimentally assess
public perceptions of normal-weight, overweight, or obese
Physician selection
Trust
2
Trust, z-scores
Physician selection,
z-scores
2
1
0
–1
–2
0
–1
–2
–2
0
2
Fat Phobia scale, z-scores
NW phys.
OW phys.
–2
OB phys.
OW phys.
OB phys.
Following advice
Compassion
2
0
2
Fat Phobia scale, z-scores
NW phys.
2
Following advice,
z-scores
Compassion, z-scores
1
1
0
–1
–2
1
0
–1
–2
–2
0
2
Fat Phobia scale, z-scores
NW phys.
OW phys.
OB phys.
–2
0
2
Fat Phobia scale, z-scores
NW phys.
OW phys.
OB phys.
Figure 2. Condition-specific regression slopes for the anti-fat attitudes effect on trust toward physicians. Note. Each graph in the figure
illustrates one of the four primary outcome variables: (a) physician selection, (b) trust towards physician, (c) compassion towards physician,
(d) following physician’s advice. Plotted slopes reflect the parameter estimates shown in Table 3. Experimental conditions: NW ¼ normalweight physician, OW ¼ overweight physician, OB ¼ obese physician. Outcome and fat phobia variables are z-standardized; higher fat phobia
scores indicate more weight bias.
& 2013 Macmillan Publishers Limited
International Journal of Obesity (2013) 1415 – 1421
Physicians’ body weight and patient attitudes
RM Puhl et al
1420
Table 3.
Regression models with interaction effects of experimental condition and anti-fat attitudes
Physician selection
Trust
Compassion
Following advice
0.461***
0.637***
0.495***
0.664***
0.190
0.184
0.413***
0.495***
0.382***
0.484***
0.209*
0.172
0.599***
0.455***
0.700***
0.324*
0.315*
0.436***
0.773***
0.010
NW physician
OW physician
OB physician
Fat phobia (z-scores)
NW physician fat phobia
OW physician fat phobia
OB physician fat phobia
BMI (centered)
0.025**
0.030***
0.010
Constant
0.365***
0.390***
0.129
N
358
358
358
0.255**
0.307***
358
Abbreviations: BMI, body mass index; NW, normal weight; OB, obese; OW, overweight. Note: ordinary least squares regression models using multiply imputed
data for BMI, M ¼ 20; BMI is centered around its mean in each of the 20 imputed data sets; all dependent variables and the fat phobia scale are z-standardized;
significance levels: * Po0.05, ** Po0.01, ***Po0.001. Interpretation: constants reflect the mean of the dependent variable for respondents with an average BMI in
the normal-weight doctor condition, and the fat phobia effect reflects the anti-fat attitude slope for respondents in that condition; the OW physician fat phobia
and OB physician fat phobia effects reflect the differences in anti-fat attitude slopes between the overweight and obese doctor conditions, respectively, and the
normal-weight doctor condition. The experimental condition main effects reflect the differences in baselines between the three experimental groups.
physicians and how these weight categories (and personal
attitudes about obese persons) affect public opinions about the
doctor–patient relationship such as physician selection, physician
trust and following medical advice. Findings show that there is a
negative weight bias toward physicians who are perceived to be
overweight or obese. Specifically, respondents report more
mistrust of physicians who are overweight or obese, are less
inclined to follow their medical advice and are more likely to
change providers if their physician appeared overweight or obese,
compared to normal-weight physicians who elicit more favorable
opinions from respondents. These biases remained present
regardless of participants’ own body weight, and were more
pronounced among individuals who demonstrated stronger
weight bias toward obese persons in general.
While health providers have been documented to hold negative
attitudes and stereotypes toward their obese patients (see Puhl
and Heuer1) this study indicates that if providers are themselves
struggling with excess weight, they too may be vulnerable to
weight bias from patients. Previous research shows that health
behaviors modeled by providers may have important implications
for the adoption of healthy, or even unhealthy, behaviors of
patients.20,29 Our findings add to this literature, suggesting that a
provider’s body weight may lead to biased perceptions by
patients that could impair the quality of patient–provider
interactions and potentially even patient compliance with their
provider’s health advice.
The fact that participants responded negatively to excess
weight among health providers without the provision of any
additional health information about the provider further suggests
that participants made assumptions about the health status and
health behaviors of the physician based on body weight alone.
Stigma-reduction efforts to reduce weight bias among health
professionals have emphasized the importance of challenging
stereotypes and recognizing the complex etiology of obesity as
determined by multiple genetic, biological and environmental
factors, rather than simply personal willpower or discipline to
engage in healthier lifestyle behaviors.30,31 It may be that similar
approaches are needed to educate patients (and the general
public) about weight bias, to help challenge stereotypes that
could ultimately threaten provider–patient interactions and the
extent to which patients follow advice and feel comfortable
discussing their own health concerns.
International Journal of Obesity (2013) 1415 – 1421
Interestingly, findings revealed that there is more similarity
across experimental conditions regarding perceived compassion
and bedside manner of physicians, such as a physician listening
carefully to the patient, understanding the patient’s health
concerns and the difficulties of losing weight, and creating
a comfortable environment for patients to express their health
concerns. This suggests that a physician’s excess body weight may
have less impact on a patient’s perceptions of his/her bedside
manner or ability to understand and listen to the patient, but may
nevertheless threaten patient perceptions of their credibility, level
of trust and inclination to follow medical advice. In light of the
present findings, it seems warranted to examine whether
providers perceive these biases from patients, and to what extent
they feel weight bias influences their effectiveness in delivery of
health care or the quality of interactions with patients.
Findings from the present study raise several additional
questions that warrant research attention. First, it is unclear
whether or not a physician’s body weight would affect patient
adherence to medical advice beyond advice related to weight
management and health behaviors. It may be that weight biases
from patients toward overweight or obese physicians are most
pronounced for medical advice that specifically addresses weightrelated health, but less so for medical advice related to other
aspects of health. It will be informative for additional research to
examine these issues. Second, as considerable disease management is performed by nurses and health professionals other than
physicians, it will be important to examine whether similar
findings are observed toward overweight or obese nurses,
dietitians, psychologists, and other health providers.
Several limitations should be noted. The cross-sectional nature
of the study precludes causal inferences from the present findings.
Given that participants’ reactions were assessed via self-report, it
will be important to examine whether weight biases by patients
toward providers affect actual patient outcomes such as their
selection of physicians or adherence to a provider’s medical
advice. In addition, participant weight and height were selfreported; however, research indicates high concordance between
objective and self-reported measures of height and weight for
adults.32 The weight distribution in the present sample contained
a higher percentage of individuals with a BMI in the normalweight range compared to the general US population, so it would
be useful to assess perceptions of physicians’ body weight in
& 2013 Macmillan Publishers Limited
Physicians’ body weight and patient attitudes
RM Puhl et al
1421
samples with more individuals in higher weight categories. Finally,
it will be important to identify whether similar weight biases
emerge in a more ethnically diverse sample, and whether
attitudes differ according to whether the provider is a male or
female, or among parents seeking treatment for children with
nutritional or weight-related issues.
In conclusion, this study suggests that providers perceived to be
overweight or obese may be vulnerable to biased attitudes from
patients, and that providers’ excess weight may negatively affect
patients’ perceptions of their credibility, level of trust and
inclination to follow medical advice. More research is needed
to understand the prevalence of patient weight biases and the
impact these have on providers, patient–provider interactions and
patient outcomes. Given that both patients and providers struggle
with excess weight, and that weight stigmatization remains a
socially acceptable and prevalent form of bias,1,33 efforts are
needed to reduce weight bias in the health-care environment to
help remove barriers that may otherwise interfere with providers’
provision of care and health-care experiences for patients.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
ACKNOWLEDGEMENTS
This research was supported by a grant from the Rudd Foundation.
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